HOUSING EXEMPTION FORM

Proposed County of Residence*

Entry Term*

Name*

First Middle Last

Date of Birth*

Student ID*

Proposed Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone*

Cell Phone*

Email*

All students are required to live on campus at Tusculum, unless you meet one of the exceptions below. If you wish to apply for an exemption, please complete and sign this form. Your signature implies responsibility for the accuracy of the document. You are further attesting that you understand that, as a student of Tusculum, you may be held responsible for your actions off campus, and must not reflect behaviors unbecoming to Tusculum students.

Understanding the above, I wish to apply for an exemption to the housing requirement on the following grounds:*

I have attached a notarized letter indicating that I am living with a parent or legal guardian within a 50-mile radius of the Greeneville campus (may be completed in presence of a Tusculum official through admission/registration process) by July 1st;
I am 21 years of age or older and in good academic and student conduct standing by July 1st;
I am a Junior with a minimum of 60-credit hours and in good academic and student conduct standing (this excludes dual enrollment and AP credits) (please attach unofficial transcripts);
I am married (copy of Marriage Certificate/License required);
I have a dependent child (copy of child’s birth certificate required); or
I am a military veteran and have served at least one-year active duty in the military.

I realize that this is only a request for housing exemption. I am not exempt from living on campus until I receive a letter granting exemption from the Student Affairs Office.

Student Signature*

Please type your name

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HOUSING EXEMPTION FORM

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